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General NPI Number Information
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NPI Number | 1992821706
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Entity Type | Organization
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Legal Business Name | ST. CLOUD TECHNICAL COLLEGE COMMUNITY DENTAL CLINIC
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Dates
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Enumeration Date | 03/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1540 NORTHWAY DR
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City | SAINT CLOUD
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State | MN
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Zip | 56303-1240
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Country | US
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Telephone | 320-308-5310
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Fax | 320-308-5055
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Provider Business Mailing Address
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Address Line | 1540 NORTHWAY DR
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City | SAINT CLOUD
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State | MN
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Zip | 56303-1240
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Country | US
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Telephone | 320-308-5310
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Fax | 320-308-5055
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Authorized Official
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Title or Position | CLINIC COORDINATOR
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Name | MELISSA LINDGREN
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Credential |
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Telephone | 320-308-5310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7913
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License Number State | MN
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